Febrile Child OSCE - Meningitis

Case Overview

• Age/Sex: 11-year-old male
• Occupation: Primary school pupil
• Setting: Emergency Department; parent (mother) is primary historian
• Chief complaint: "He's got a fever and a rash — he won't wake up properly"

Patient Script

Who I Am

I'm an 11-year-old boy in Year 6 at school.

What Brings Me In

He's been high feverish since last night and this morning I found a blotchy rash that doesn't fade — now he's very sleepy and vomiting.

My Story

It started with a high fever yesterday evening and he felt hot and a bit miserable. He had a very high temperature this morning (about 39–40°C) and was complaining of a bad headache and some neck pain when he tried to look up. About 4 hours ago I noticed small purple spots on his legs and arms that didn't fade when I pressed on them. He vomited twice this morning and has become much more sleepy — he was hard to wake an hour ago. He's also saying lights hurt his eyes. He had a runny nose and sore throat a week ago that seemed to improve (we thought it was a cold). He has asthma but hasn't needed his inhaler today. He has a small graze on his knee from football yesterday but it was tiny.

My Medical Background

• Past medical history: mild asthma (infrequent salbutamol), otherwise well
• Medications: salbutamol inhaler as needed; paracetamol given at home
• Allergies: none known
• Immunisation: routine childhood vaccinations reportedly up to date (we have the record at home)
• Social: lives with parents and younger sister; attends school; no recent travel abroad
• Family history: no unusual bleeding disorders or immunodeficiency

What I Think & Worry About

• I think he might have a bad infection and I'm really worried he's going downhill fast.
• I'm frightened he might have meningitis because of the headache, neck pain and rash.
• I'm worried about hospital tests and needles — and I want him to be kept comfortable and not alone.

If You Ask Me About Other Symptoms...

• Fever: "He was hot since last night and yesterday evening was when it started to get bad."
• Headache: "He keeps saying his head really hurts and he doesn't like the light."
• Neck stiffness: "He said his neck was sore when he tried to look up this morning."
• Vomiting: "He vomited twice this morning, hasn't kept food down."
• Rash: "They started as tiny red spots on his legs and now there are more and some are purple — they don't go away when I press them."
• Breathing: "He's breathing faster than usual but hasn't been wheezy today."
• Conscious level: "He was harder to wake this morning, he kept drifting off while we were talking to him."
• Recent illnesses/exposures: "He had a sore throat a week ago which got better — he also had a playground fall yesterday with a small graze."
• Meds given at home: "I gave him paracetamol about 2 hours ago but it didn't settle the fever much."

---

Clinical Summary

Examination

• General: Pale, ill-looking boy, intermittently drowsy, responds to voice but somnolent between stimulation (GCS ~13)
• Temperature: 39.8°C
• Heart rate: 150 bpm (tachycardic)
• Blood pressure: 85/52 mmHg (age-appropriate hypotension for age)
• Respiratory rate: 30/min (tachypnoea)
• Oxygen saturation: 96% on room air
• Capillary refill: 4 seconds; cool peripheries
• Skin: widespread petechial/purpuric non-blanching rash on limbs and trunk
• Neurological: neck stiffness positive on passive flexion; photophobia; no focal limb weakness; pupils equal and reactive
• Other: no clear source of focal infection on ENT/chest/abdomen; small superficial graze on knee

Investigations

• Point-of-care glucose: 6.1 mmol/L (normal)
• Full blood count: WBC 16.5 x10^9/L (neutrophil-predominant), Platelets 55 x10^9/L (thrombocytopenia)
• CRP: 240 mg/L (markedly raised)
• Blood gas (venous): pH 7.31, lactate 5.2 mmol/L (metabolic acidosis with elevated lactate — concern for sepsis)
• Coagulation: INR 1.9, aPTT 48 s (prolonged) (consumptive coagulopathy/DIC pattern)
• Blood cultures: taken (results pending)
• Urgent Gram stain of blood (if rapid reporting available): may show Gram-negative diplococci (possible) — note: confirmatory culture/PCR required
• Lumbar puncture: deferred at presentation due to thrombocytopenia and hemodynamic instability
• Chest X-ray: no focal consolidation

Diagnosis

• Primary diagnosis: Acute bacterial meningitis with meningococcal septicaemia (meningococcemia)

  • Evidence: acute high fever, severe headache, neck stiffness, photophobia, non-blanching petechial/purpuric rash, rapid deterioration in level of consciousness, signs of shock (tachycardia, hypotension, elevated lactate), thrombocytopenia and coagulopathy consistent with disseminated meningococcal infection.

• Important differentials:

  • Severe sepsis/septic shock due to other organisms (e.g., Streptococcus pneumoniae) — feasible but the non-blanching rash and age make Neisseria meningitidis more likely.
  • Viral meningitis — less likely given severity, rash and septic physiology.
  • Immune thrombocytopenic purpura (ITP) causing rash — would not explain fever, neck stiffness, systemic toxicity and high CRP.
  • Henoch–Schönlein purpura (HSP) — purpuric rash typically on buttocks/legs and associated abdominal pain and arthralgia, less likely to cause high fever/sepsis picture.

Management

• Immediate (within minutes): follow ABCs; call for paediatric resuscitation team and senior paediatric/ED clinician; arrange monitoring and paediatric ICU review.
• Airway/Breathing: give high-flow oxygen and ensure airway patency; prepare for escalation if GCS falls.
• Circulation: obtain two large-bore IV accesses; give cautious fluid boluses (e.g., 20 mL/kg isotonic crystalloid) with frequent reassessment; start vasopressors early if hypotension persists (transfer to PICU).
• Antibiotics: give immediate empiric IV antibiotics without delay after blood cultures are taken — recommended empiric therapy for suspected meningococcal sepsis/meningitis (e.g., ceftriaxone or cefotaxime iv; if local guidance recommends benzylpenicillin for suspected meningococcus, give immediately). Do not delay antibiotics for lumbar puncture or imaging.
• Diagnostics/supportive: take blood cultures and other relevant samples before antibiotics if this will not delay therapy; defer lumbar puncture until stabilised and coagulation/platelets adequate.
• Infection control/public health: implement droplet precautions; notify public health/communicable disease team urgently for contact tracing and prophylaxis of close contacts (e.g., rifampicin or ciprofloxacin as per local guidance).
• Haematology: correct coagulopathy and consider platelet transfusion if bleeding or prior to invasive procedures and if platelets remain very low; monitor for DIC and treat supportively.
• Analgesia/antipyretic: paracetamol for comfort; treat vomiting and maintain hydration.
• Disposition: urgent admission to paediatric intensive care for ongoing management, monitoring for raised intracranial pressure, vasopressor support and consideration of adjunctive therapies.

Key Learning Points

• A non-blanching petechial or purpuric rash in a febrile child is a red flag for meningococcal disease and requires immediate assessment and often empiric antibiotics.
• In suspected meningococcal sepsis/meningitis, obtain blood cultures promptly but do not delay empiric intravenous antibiotics and resuscitation; lumbar puncture should be deferred if there is shock, coagulopathy, or raised intracranial pressure.
• Early recognition of sepsis physiology (tachycardia, hypotension, high lactate, prolonged capillary refill) and rapid escalation to paediatric ICU with appropriate supportive measures (fluid resuscitation, vasopressors, urgent antibiotics) are critical to improve outcomes.